Original Article

Med Lasers 2020;9(2):166-171

https://doi.org/10.25289/ML.2020.9.2.166
pISSN 2287-8300ㆍeISSN 2288-0224

Effectiveness of the Pico-toning Technique for the Treatment

of Melasma with a Low Fluence 1,064-nm Nd:YAG Laser in
Asian Patients
Dong Gyu Kim Background and Objectives
Seung Min Nam Melasma is an acquired pigmentary disorder characterized by brown or
Jin Soo Shin dark brown colored macules and patches which mostly involve the face.
Eun Soo Park Compared to nanosecond lasers, picosecond lasers have fewer adverse
effects on surrounding tissues and give better results for melanin
fragmentation. The purpose of this study was to evaluate the efficacy of
Department of Plastic and Reconstructive the pico-toning technique using a low fluence 1,064-nm Nd:YAG laser on
Surgery, Soonchunhyang University Bucheon melasma patients.
Hospital, Soonchunhyang University College of
Materials and Methods
Medicine, Bucheon, Korea
This study is a retrospective analysis of melasma cases treated using the
pico-toning technique from June 2017 to November 2020. Based on
photographic images, the modified Melasma Area and Severity Index
(mMASI) score was blind evaluated by two independent plastic surgeons.
Patient satisfaction was assessed through a 5-point Likert scale
questionnaire after treatment sessions. All adverse effects and
complications were reviewed based on medical records.
Results
A total of 23 patients were included in the study. The mMASI scores for
baseline and 2 months after the last procedure were 5.1 ± 1.4 and 2.6 ±
0.4, respectively. The mean mMASI score reduced significantly after the
treatment session (p < 0.05). The patient satisfaction score with the
procedure was 3.8 ± 1.0. The subject satisfaction score and difference in
the mMASI score before the procedure and 2 months after the last
procedure showed a significant correlation. Adverse effects observed in
this study were erythema (n = 1) and edema (n = 1).
Conclusion
The results of the study show that the pico-toning technique is effective in
Received December 8, 2020 Asian patients with melasma. We believe that safety was enhanced by
Accepted December 18, 2020
using low fluence, and thus better results were achieved with fewer
Correspondence adverse effects.
Eun Soo Park
Department of Plastic and Reconstructive, Key words
Soonchunhyang University Bucheon Hospital, Picosecond; Laser toning; Pigmentation; Skin pigmentation; Melanosis
170 Jomaru-ro, Bucheon 14584, Korea
Tel.: +82-32-621-5319
Fax: +82-32-621-5016
E-mail: peunsoo@schmc.ac.kr

C Korean Society for Laser Medicine and Surgery

CC This is an open access article distributed under the

terms of the Creative Commons Attribution Non-

Commercial License (http://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted non-
commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.

166 Medical Lasers; Engineering, Basic Research, and Clinical Application


INTRODUCTION
Melasma is an acquired pigmentary disorder and is
characterized by brown or dark brown colored macules
and patches.1 Although the exact cause of the onset is un-
known, ultraviolet light, genetic predisposition, hormonal
effect, pregnancy, and phototoxic drugs are the main
factors. And it is also a cause of deterioration.2,3 It usually
occurs on the face and rarely occurs in other areas.
The use of sunscreens to block ultraviolet light and top-
ical anti-melanogenesis agents including hydroquinone,
retinoic acid, glycolic acid and corticosteroid are common
first-line treatments for melasma.4,5 Hydroquinone, which
is a tyrosinase inhibitor, has been proven to be effective
in the treatment of melasma but is known to be effec-
tive only in epidermal type melasma.6 A chemical peel to
remove melanin is also one of the treatment options and
glycolic acid and salicylic acid are available. However, this
also has a disadvantage that it is not effective in mixed
type or dermal type melasma and that recurrence may
occur.7
Recently, laser-based treatment of hyperpigmentation
conditions of the skin including melasma has been pro-
posed as an adjunctive treatment.7 The main mechanism
in the treatment of pigmentation using a laser is that pho-
to-thermal energy targets the melanin pigment to cause
“selective photothermolysis”.8 Lasers widely used in the
treatment of pigmented skin include Q-switched Ruby la-
ser, Q-switched alexandrite laser and Q-switched Nd:YAG
laser.9,10 However, none of the laser treatments are con-
sistently effective enough to become the gold standard,
and complications including pain, erythema, and post-
inflammatory hyperpigmentation or hypopigmentation
are frequently reported.10,11
Picosecond laser uses extremely short pulse duration,
that is, 300-500 picosecond pulse duration. Because of
these properties, it can deliver higher energies and shows
a lower photothermal effect than other laser technolo-
gies with a longer pulse duration range. As a result, it has
the advantage of minimizing post-procedure pain and
minimizing skin discoloration after laser treatment.12 In
the same fluence, the picosecond laser also causes more
melanin fragmentation with higher energy than the nano-
second laser.13 Therefore, when using picosecond laser,
melasma can be treated with low fluence and satisfac-
tory results can be obtained with minimal side effects,14,15
which we refer to as the ‘pico-toning technique’.
The purpose of this study was to evaluate the efficacy of
the pico-toning technique using a low fluence picosecond
1,064-nm Nd:YAG laser in melasma patients.
VOLUME 9 NUMBER 2 December 2020
Pico-toning Technique for the Treatment of Melasma
Dong Gyu Kim, et al.
Original Article
SUBJECTS AND METHODS
Subjects and study design
This study is a retrospective analysis of the cases treat-
ed using picosecond 1064-nm laser treatment in patients
diagnosed with melasma from June 2017 to November
2020. The patient's gender, age, clinical finding, the pa-
rameter for the performed procedure, and photographic
images were collected from medical records. Patients
with underlying skin disease, immunodeficiency, tak-
ing hormone replacement therapy, current pregnancy,
breastfeeding were excluded from the study. In addition,
patients who had been treated with topical agents such as
retinoid, corticosteroid, hydroquinone within one month
were excluded from the study. Photographic images
were performed prior to the procedure and were taken
2 months after the last procedure. Photographic images
were obtained under the same condition. 2D images of
the whole face were taken in a natural manner (right lat-
eral, right lateral 45°, central, left lateral 45°, left lateral).
This study was approved by the Institutional Review Board
of Soonchunhyang University Bucheon Hospital and per-
formed in accordance with the Declaration of Helsinki.
Laser treatment
A picosecond Nd:YAG laser device, PICOCARE® (WON-
TECH, Daejeon, Korea) was used in this study. Prior to
initiation of treatment, a topical anesthetic agent (EMLA®;
Recipharm Karlskaga AB, Karlskoga, Sweden) was ap-
plied to the treatment area for 1 hour. After that, the
topical anesthetic agent was wiped out and laser treat-
ment was performed. Picosecond laser treatment was
performed at a wavelength of 1,064-nm, 7-10 mm spot
size, 0.5-0.8 J/cm2 fluence, 10 Hz frequency, maximum 3
passes. The treatment protocol is presented in Table 1.
Evaluation
Pictures taken before the procedure and 2 months af-
ter the last procedure were evaluated by two blinded, in-
dependent plastic surgeons. The tool used for the efficacy
assessment is the modified melasma area and severity
index (mMASI) scoring system. Unlike conventional MASI,
the mMASI score is calculated with two evaluation fac-
tors, including area of involvement (A) and darkness (D).
Table 1. Parameters of Pico-toning technique
Wavelength Spot size Fluence (J/ Frequency
Pass
(nm) (mm) cm2) (Hz)
1,064 7-10 0.5-0.8 10 Maximum 3
167
Area of involvement are scored as follows : 0 = absent,
1 ≤ 10%, 2 = 10%-29%, 3 = 30%-49%, 4 = 50%-69%, 5 =
70%-89%, and 6 = 90%-100%. Darkness are scored as
follows: 0 = absent, 1 = slight, 2 = mild, 3 = marked, and
4 = severe. Total range of score is 0-24. The evaluation
was conducted by dividing the area into Forehead(f), right
malar area(rm), left malar area(lm), and chin(c), and the
calculation formula is as follows.16
Modified MASI total score =
0.3*A(f)*D(f) + 0.3*A(rm)*D(rm) + 0.3*A(lm)*D(lm) +
0.1*A(c)*D(c)
Two months after the last procedure, the patient's sat-
isfaction with the treatment was evaluated. Subject satis-
faction was evaluated on a 5-point Likert scale question-
naire.(1 = Very unsatisfied, 2 = Unsatisfied, 3 = Neutral, 4
= Satisfied, 5 = Very satisfied) A correlation analysis study
was conducted between the subject satisfaction score
and difference in the mMASI score before the procedure
and 2 months after the last procedure.
All adverse events and complications, including ery-
thema, edema, bullae, post inflammatory hyperpigmen-
tation, and hypopigmentation, on medical records were
reviewed during treatment and visitation.
Statistical analysis
Statistical analysis was performed using Data were
analyzed using SPSS Statistics for Windows, Version
26.0 (IBM Corp, Armonk, NY, USA). The Wilcoxon-signed
rank test was used to compare the mMASI scores of pre-
10 *
9
8
7
mMASI score
6
5 3
4
3 2
2
1
0
Before the treatment 2 months after
the last procedure
Fig. 1. The modified melasma area and severity index (mMASI)
score of baseline and 2 months after the last procedure. The baseline
and 2 months after the last procedure are 5.1±1.4 and 2.6±0.4,
respectively. The mean mMASI score reduced significantly. *p <
0.05.
168 Medical Lasers; Engineering, Basic Research, and Clinical Application
treatment and 2 months post-treatment visits. Spearman
correlation test was used to compare the correlation
between the subject satisfaction score and the difference
in the mMASI score before the procedure and 2 months
after the last procedure. Descriptive statistics are ex-
pressed as means ± standard deviations. A p-value of less
than 0.05 was considered statistically significant.
RESULTS
A total of 23 patients who were clinically diagnosed with
melasma were included in the study. The mean patient
age was 51.1 ± 9.3 years. The baseline mMASI score was
5.1 ± 1.4. The mMASI score performed 2 months after
the last procedure was 2.6 ± 0.4 (Fig. 1). Following the
laser treatment, the mean mMASI score decreased sig-
nificantly. (p < 0.05) Treatment sessions that the patients
underwent the pico-toning technique was 5.0 ± 1.3. After
treatment, patients' satisfaction with the procedure was
3.8 ± 1.0, with 4 points (satisfied) being the most frequent.
The results of Spearman's correlation coefficient showed
significant relationships between the subject satisfaction
score and difference in the mMASI score before the pro-
cedure and 2 months after the last procedure (r = 0.844, p
< 0.001) (Fig. 2). The photographic finding of a case before
the treatment and 2 months after the last procedure is
presented (Fig. 3). Adverse effects observed in this study
were erythema (n = 1) and edema (n = 1), and no recur-
rence, post-inflammatory hypopigmentation, or hyper-
pigmentation was observed. The demographic data of the
patients included in the study have been listed in Table 2.
5
Subjects satisfaction score
4
1
0 2 4 6
Difference in the mMASI score
Fig. 2. Scatter plot of the subject satisfaction score and difference in
the mMASI score. The scatter plot shows significant relationships
between the subject satisfaction score and difference in the mMASI
score before the procedure and 2 months after the last procedure (r = 
0.844, p < 0.001).
 Pico-toning Technique for the Treatment of Melasma
Dong Gyu Kim, et al.

Original Article
Fig. 3. Photographic finding of a case before and after the treatment. Before the treatment (upper) and 2 months after the last procedure (lower).

Table 2. Demographic characteristics plasma is generated as a result of free “seed” electrons

Results by multiphoton absorption or by thermionic emission,18
Charateristics
(Mean ± SD or N (%)) leading to breakdown.19 In the skin, melanin provides free
Age 51.1±9.3 seed electrons by laser-heated melanin, and the resulting
Gender plasma forms vacuoles in the epidermal layer. Based on
Female 23 (100%) these theoretical backgrounds, a picosecond laser can be
Adverse effect judged as an appropriate treatment option for melasma.
Erythema 1 (4.3)
Research on the treatment of melasma using lasers
Edema 1 (4.3)
Bullae 0 (0) has continued for the past decade, especially the treat-
Post-inflammatory hyperpigmentation 0 (0) ment of melasma using Q-switched Nd:YAG laser.20-22
Post-inflammatory hypopigmentation 0 (0) In these studies, the treatment showed effective results,
SD, standard deviation.
but post-laser hyperpigmentation has occurred in sev-
eral cases, and there has been frequent recurrence.23,24
In a comparative study of split face treatment using Q-
DISCUSSION switched Nd:YAG laser and picosecond laser, picosecond
laser showed faster and better melasma clearance rate.25
Selective photothermolysis, presented in 1983, is the Another study proved that the use of hydroquinone cream
concept that specific wavelengths can be used to target treatment in combination with a 1,064-nm picosecond
specific chromophores.8 Using a duration shorter than laser showed better results than when using hydroqui-
the target's thermal relaxation time in terms of pulse du- none cream alone, and also proved the safety of using a
ration can reduce damage to the surrounding tissue. With 1064nm picosecond laser.26
the advent of the picosecond laser, it was found that tar- Picosecond laser can target not only melanin but also
get destruction is possible in a state where there is little hemoglobin, and dermal hemorrhage has been con-
heating or damage to the surrounding tissue in the pulse firmed histologically.19 Therefore, it is essential to control
duration range of 10-100 picoseconds, and this leads to fluence for proper energy delivered to reduce adverse
the concept of photomechanical effect.17 Laser-induced effects. In 1999, Goldberg et al. introduced the concept of
optical breakdown (LIOB) refers to the process that laser toning for the first time by conducting skin resurfac-

VOLUME 9 NUMBER 2 December 2020 169

ing using low fluence Nd:YAG.27 In subsequent studies,
the application of low fluence showed an effect on skin re-
juvenation and skin pigmentation at the same time.24,28,29
Kang et al. introduced a dual toning technique combining
two modes, nanosecond and microsecond, using 1,064-
nm Nd:YAG.30 We subsequently named it the "pico-toning
technique" as laser toning using a picosecond laser.
This study demonstrates the efficacy and safety of pico-
toning technique with a low fluence picosecond 1,064-
nm Nd:YAG laser in Asian female melasma patients.
The limitations of this study are that the study design is a
retrospective study of treatment protocol solely with pico-
toning technique, the number of patients is small, and
there is a lack of long-term follow-up data after the end
of treatment. We look forward to conducting large-scale
prospective studies in the future, including comparisons
with other laser or topical treatment options for melasma.
ACKNOWLEDGEMENTS
This work was supported by the Soonchunhyang Uni-
versity Research Fund.
CONFLICT OF INTEREST
The authors declare no conflicts of interest.
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Pico-toning Technique for the Treatment of Melasma
Dong Gyu Kim, et al.
Original Article
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How to cite this article: Kim DG, Nam SM, Shin JS, Park
ES. Effectiveness of the pico-toning technique for the treat-
ment of melasma with a low fluence 1,064-nm Nd:YAG
Laser in Asian patients. Med Lasers 2020;9:166-171. https://
doi.org/10.25289/ML.2020.9.2.166
171